ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN

Transcription

1 ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN The provisions in Attachment II and the MMA Exhibit apply to this Specialty Plan, unless otherwise specified in this Exhibit. Section I. Definitions and Acronyms A. Definitions Serious Mental Illness General descriptor for one, or a combination of the following conditions: Psychotic disorders, bipolar disorder, major depression, schizo-affective disorder, delusional disorder, obsessive-compulsive disorder. B. Acronyms SMI Serious Mental Illness Section II. General Overview In accord with the order of precedence listed in Attachment I, any additional items or enhancements listed in the Managed Care Plan s response to the Invitation to Negotiate are included in this Exhibit by this reference. Section III. Eligibility and Enrollment A. Eligibility 1. Specialty Population Eligibility Criteria a. The specialty population eligible to enroll in this Specialty Plan shall consist of only those mandatory and voluntary recipients specified in Attachment II and its Exhibits who meet the following criteria: B. Enrollment (1) Diagnosed with an SMI, as defined in this Exhibit. 1. Specialty Plan-Specific Claims-Based Population Identification a. The Agency shall identify the specialty population eligible for enrollment in the Specialty Plan through an Agency-approved SMI algorithm. b. The SMI algorithm data elements include: (1) SMI diagnosis codes; and AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 1 of 13

2 (2) List of medications used to treat SMI. c. The Agency may revise the SMI algorithm as needed to update the process of identifying recipients with an SMI. The Agency shall conduct a review of the SMI algorithm on at least an annual basis. The Specialty Plan shall collaborate with the Agency in such reviews and provide consultation to the Agency regarding revisions to data elements upon request. 2. Specialty Plan-Specific Verification of Eligibility a. The Specialty Plan shall have policies and procedures, subject to Agency approval, to verify the specialty population eligibility criteria of each enrolled recipient. The Specialty Plan shall submit policies and procedures regarding screening for specialty population eligibility prior to implementation of such policies and procedures. b. Policies and procedures regarding screening for specialty population eligibility must include: (1) Timeframes for verification of specialty population eligibility criteria; (2) Mechanisms for reporting the results of specialty population eligibility screening to the Agency; (3) Mechanisms for submitting disenrollment requests for enrollees that do not meet specialty population eligibility criteria; and (4) Such other verifications, protocols, or mechanisms as may be required by the Agency to ensure enrolled recipients meet defined specialty population eligibility criteria. c. The Specialty Plan may develop and implement, subject to Agency approval, policies and procedures to screen recipients meeting the Specialty Plan eligibility criteria and who have not been identified by Agency. The Agency may enroll such recipients upon receipt of verification pursuant to the screening requirements specified above. C. Disenrollment The Specialty Plan shall submit involuntary disenrollment requests to the Agency or its designee, in a format and timeframe prescribed by the Agency, for each enrollee that does not meet the Specialty Plan eligibility criteria, pursuant to the specialty population screening requirements specified above. D. Marketing The Specialty Plan shall develop and implement, subject to Agency approval, policies and procedures that ensure the confidentiality of recipients diagnosed with an SMI in the conduct of any marketing activities pursuant to Attachment II and its Exhibits. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 2 of 13

3 Section IV. Enrollee Services and Grievance and Appeal System A. Enrollee Materials The Specialty Plan shall develop and implement, subject to Agency approval, policies and procedures that ensure the confidentiality of enrollees diagnosed with an SMI in the distribution of all enrollee materials pursuant to Attachment II and its Exhibits. B. Enrollee Services There are no additional enrollee services provisions unique to the Specialty Plan. C. Grievance System There are no additional grievance system provisions unique to the Specialty Plan. Section V. Covered Services A. Required Benefits There are no additional required benefits provisions unique to the Specialty Plan. B. Expanded Benefits 1. Specialty Plan-Specific Expanded Benefits a. In addition to the minimum covered services set forth in Attachment I, the Specialty Plan shall offer an Intensive Outpatient Therapy expanded benefit in accordance with the provisions of Attachment II and its Exhibits. C. Excluded Services There are no additional excluded services provisions unique to the Specialty Plan. D. Coverage Provisions There are no additional coverage provisions unique to the Specialty Plan. E. Care Coordination/Case Management 1. Care Coordination/Case Management Program Description a. In addition to the provisions set forth is Attachment II and Exhibits, the Specialty Plan shall provide care coordination/case management to enrollees appropriate to the needs of persons meeting the Specialty Plan eligibility criteria. The Specialty Plan shall develop, implement and maintain an Agency-approved care coordination/case management program specific to the specialty population. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 3 of 13

4 b. The Specialty Plan shall submit a care coordination/case management program description annually to the Agency, at a date specified by the Agency. The care coordination/case management program description shall, at a minimum, address: (1) The organization of care coordination/case management staff, including the role of qualified and trained nursing, social work, pharmacy, and behavioral health personnel in case management processes; (2) Maximum caseload for case managers with an adequate number of qualified and trained case managers to meet the needs of enrollees; (3) Case manager selection and assignment, including protocols to ensure new enrollees are assigned to a case manager immediately; (4) Protocols for initial contact with enrollees, as well as requirements for the frequency and type of ongoing minimum contacts with enrollees; (5) Surrogate decision-making, including protocols if the enrollee is not capable of making his/her own decisions, but does not have a legal representative or authorized representative available; (6) Outreach programs that make a reasonable effort to locate and/or re-engage enrollees who have not received follow-up care for ninety (90) days or more; (7) Enrollee access to case managers, including provisions for access to back-up case managers as needed; (8) Assessment and reassessment of the acuity level and service needs of each enrollee; (9) Care planning for mental health treatment that is tailored to the individual enrollee and is in agreement with evidenced based guidelines for mental health treatment; (10) Coordination of care through all levels of practitioner care (primary care to specialist); (11) Monitoring compliance with scheduled appointments, laboratory results and medication adherence; (12) Coordination with and referrals to providers of behavioral health services for enrollees with co-occurring mental health and/or substance abuse disorders; (13) Interventions to avoid unnecessary use of emergency departments, inpatient care, and other acute care services; (14) Patient education to assist enrollees in better management of their health issues including the principles of recovery and resiliency. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 4 of 13

5 (15) Linking enrollees to community or other support services. c. The Specialty Plan shall coordinate services with DCF, Florida Assertive Community Teams, and any other public or private organizations that provide services to the specialty plan population to ensure effective program coordination and no duplication of services. The Specialty Plan s care coordination/case management program description must include protocols and other mechanisms for accomplishing such program coordination. The Specialty Plan shall collaborate with the Agency and DCF to develop such protocols and other mechanisms as may be required for effective program coordination. 2. Care Coordination/Case Management Staff Qualifications a. The Specialty Plan shall have sufficient care coordination/case management staff, qualified by training, experience and certification/licensure applicable to the Specialty Plan population. b. The Specialty Plan shall establish, subject to Agency approval, qualifications for all care coordination/case management staff that include clinical training, licensure and a minimum number of years of relevant experience. The Specialty Plan may request a waiver for staff without the aforementioned qualifications on a case-by-case basis. All such waivers must be approved in writing by the Agency. 3. Case Management Supervision The Specialty Plan shall establish a supervisor-to-case-manager ratio that is conducive to a sound support structure for case managers. Supervisors must have adequate time to train and review the work of newly hired case managers as well as provide support and guidance to established case managers. A system of internal monitoring of the case management program, to include case file audits and reviews of the consistency of enrollee assessments and service authorizations, must be established and applied, at a minimum, on a quarterly basis. The results of this monitoring, including the development and implementation of continuous improvement strategies to address identified deficiencies, must be documented and made available to the Agency upon request. 4. Care Coordination/Case Management and Staff Training a. The Specialty Plan shall provide all care coordination/case managers with adequate orientation and ongoing training on subjects relevant to enrollees diagnosed with SMI. The Specialty Plan shall develop a training plan to provide uniform training to all care coordination/case management. This plan should include formal training classes as well as practicum observation and instruction for newly hired staff. b. The Specialty Plan shall provide all newly hired care coordination/case management staff orientation and pre-service training covering areas applicable to responsibilities and duties performed. c. In addition to review of areas covered in orientation, the Specialty Plan shall also provide all care coordination/case management staff with regular ongoing in-service training on topics relevant to enrollees diagnosed with an SMI. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 5 of 13

6 d. The Specialty Plan shall maintain documentation of training dates and staff attendance as well as copies of materials used for orientation, pre-service and in-service training for care coordination/case management staff. F. Quality Enhancements There are no additional quality enhancements provisions unique to the Specialty Plan. Section VI. Provider Network A. Network Adequacy Standards 1. Specialty Plan-Specific Network Capacity Enhancements a. The Specialty Plan shall select and approve its Primary Care Providers (PCPs) that practice in one of the following areas: general practice, family practice, pediatrics, obstetricians, and internal medicine. The Specialty Plan shall ensure that physicians with training and demonstrated experience in treating persons diagnosed with SMI are members of the provider network and can be designated as PCPs. The Specialty Plan may designate psychiatrists with training and demonstrated experience in primary care as PCPs. b. Notwithstanding the Provider Network Standards established in Attachment II, Section VI, Provider Network and Exhibits, the Specialty Plan shall, at a minimum, maintain enhanced provider ratios as indicated in the table (below) for the Specialty Plan. The Agency shall determine regional provider ratios based upon one hundred and twenty percent (120%) of the Specialty Plan s actual monthly enrollment measured at the first of each month, by region. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 6 of 13

7 Managed Medical Assistance Provider Network Standards Table Serious Mental Illness Specialty Plan Enhancements Urban County Rural County Regional Provider Ratios Required Providers Maximum Time (minutes) Maximum Distance (miles) Maximum Time (minutes) Maximum Distance (miles) Providers per Recipient Primary Care Provider :750 Specialists 24 Hour Pharmacy :County Behavioral Health Board Certified or Board Eligible Adult Psychiatrists :375 Board Certified or Board Eligible Child Psychiatrists :3,500 Inpatient Substance Abuse Detoxification Units Fully Accredited Psychiatric Community Hospital (Adult) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital Fully Accredited Psychiatric Community Hospital (Child) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital 2. Specialty Plan Network Adequacy Measures n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 1 bed:1,000 enrollees 1 bed:500 enrollees 1 bed:2,000 enrollees a. Notwithstanding the Provider Network Standards established in Attachment II, Section VI, Provider Network and Exhibits, the Specialty Plan shall comply with the regional standards for each measure as specified in the Provider Network Adequacy Standards Table below. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 7 of 13

8 Provider Network Adequacy Measures Table Serious Mental Illness Specialty Plan Measure The Managed Care Plan agrees that no more than percent of enrollee hospital admissions, by region, shall occur in non-participating facilities, excluding continuity of care periods, as defined in Subsection VII. H., Continuity of Care in Enrollment. Admissions through the emergency department are not included in this standard. The Managed Care Plan agrees that no more than percent of enrollee specialty care (physician specialists) utilization, by region, shall occur with non-participating providers, excluding continuity of care periods, as defined in Subsection VII. H., Continuity of Care in Enrollment. Hospital based specialists are not included in this standard. Standard B. Network Development and Management Plan Region The Specialty Plan shall address the availability and accessibility of psychiatrists and other specialty providers relevant to the specialty population in its annual network plan submitted to the Agency in accordance with Attachment II and its Exhibits. C. Provider Credentialing and Contracting 1. Provider Training Verification The Specialty Plan shall require formal training or verification of completed training for network providers in the use of behavioral health assessment tools, assessment instruments and in techniques for identifying individuals with unmet behavioral health needs, evidence based practice and the principles of recovery and resiliency. D. Provider Services 1. General Provisions The Specialty Plan shall develop and implement, subject to Agency approval, a continuing education program that provides ongoing education with continuing education (medical and non-medical) to network providers, at no cost to such providers, on topics including, but not limited to, evidence based practice, and the principles of recovery and resiliency. 2. Additional Provider Handbook Requirements a. In addition to the provisions set forth in Attachment II, Section VI, Provider Network and Exhibits, the Specialty Plan shall include Specialty Plan-specific information regarding proposed policies and procedures, to include information such as: (1) Specialized provider education requirements; (2) Requirements for care in accordance with the most recent clinical practice guidelines for psychiatric, mental health, and substance abuse treatment; AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 8 of 13

9 (3) Treatment adherence services available from the Specialty Plan; (4) PCP criteria including procedures for required use of approved assessment instruments for mental health and substance abuse; (5) Specialist Case Management policies and procedures including role of the provider in the Specialty Plan s medical case management/care coordination services; (6) Referral to services including services outside of the Specialty Plan s covered services and services provided through interagency agreements; and (7) Quality measurement standards for providers and requirements for exchange of data. E. Medical/Case Record Standards There are no additional medical/case record standards provisions unique to the Specialty Plan. Section VII. Quality and Utilization Management A. Quality Improvement 1. Specialty Plan-Specific Quality Improvement Plan Requirements a. In addition to the requirements set forth in Attachment II and its Exhibits, the Specialty Plan s Quality Improvement (QI) Plan shall include measurement of adherence to clinical and preventive health guidelines consistent with prevailing standards of professional medical practice and with standards regarding the most recent clinical and evidence- based practice guidelines for psychiatric, mental health, and substance abuse treatment. B. Performance Measures (PMs) 1. Specialty Plan-Specific Performance Measure Requirements a. In addition to the provisions set forth in Attachment II and its Exhibits, the Specialty Plan shall collect data, and report on, additional performance measures that are germane to the Specialty Plan population. b. The Specialty Plan shall collect data and report the additional HEDIS performance measures below accordance with Attachment II and Exhibits. (1) Diabetes monitoring for people with diabetes and schizophrenia; and (2) Cardiovascular monitoring for people with cardiovascular disease and schizophrenia. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 9 of 13

10 C. Performance Improvement Projects There are no additional performance improvement projects provisions unique to the Specialty Plan. D. Satisfaction and Experience Surveys There are no additional satisfaction and experience surveys provisions unique to the Specialty Plan. E. Provider- Specific Performance Monitoring There are no additional provider-specific performance monitoring provisions unique to the Specialty Plan. F. Other Quality Management Requirements There are no additional provisions unique to the Specialty Plan. G. Utilization Management The Specialty Plan shall ensure its Utilization Management Program Description, service authorization systems, practice guidelines and clinical decision-making required pursuant to Attachment II and its Exhibits are consistent with prevailing standards of professional medical practice and with standards regarding the most recent clinical practice guidelines in psychiatric, mental health, and substance abuse treatment. The Specialty Plan shall develop and implement, subject to Agency approval, policies and procedures to notify the Agency of clinical practice guidelines for psychiatric, mental health, and substance abuse treatment. H. Continuity of Care in Enrollment There are no additional continuity of care in enrollment provisions unique to the Specialty Plan. Section VIII. Administration and Management A. Organizational Governance and Staffing There are no additional organizational governance and staffing provisions unique to the Specialty Plan. B. Subcontracts There are no additional subcontracts provisions unique to the Specialty Plan. C. Information Management and Systems There are no additional information management and systems provisions unique to the Specialty Plan. AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 10 of 13

11 D. Claims and Provider Payment There are no additional claims and provider payment provisions unique to the Specialty Plan. E. Encounter Data Requirements There are no additional encounter data provisions unique to the Specialty Plan. F. Fraud and Abuse Prevention There are no additional fraud and abuse prevention provisions unique to the Specialty Plan. Section IX. Method of Payment A. Fixed Price Unit Contract There are no additional provisions unique to the Specialty Plan. B. Payment Provisions There are no additional payment provisions unique to the Specialty Plan. Section X. Financial Requirements A. Insolvency Protection There are no additional insolvency protection provisions unique to the Specialty Plan. B. Surplus There are no additional surplus provisions unique to the Specialty Plan. C. Interest There are no additional interest provisions unique to the Specialty Plan. D. Third Party Resources There are no additional third party resources provisions unique to the Specialty Plan. E. Assignment There are no additional assignment provisions unique to the Specialty Plan. F. Financial Reporting There are no additional financial reporting provisions unique to the Specialty Plan. G. Inspection and Audit of Financial Records AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 11 of 13

12 There are no additional inspection provisions unique to the Specialty Plan. Section XI. Sanctions A. Contract Violations and Non-Compliance There are no additional provisions unique to the Specialty Plan. B. Performance Measure Action Plans (PMAP) and Corrective Action Plans (CAP) There are no additional PMAP and/or CAP provisions unique to the Specialty Plan. C. Performance Measure Sanctions In addition to the provisions set forth in the MMA Exhibit, the Agency will review the Specialty Plan s data related to the performance measures specified heretofore to determine acceptable performance levels and may establish sanctions for these measures based on those levels after the first year the Contract. In addition to the provisions set forth in the MMA Exhibits, the Agency reserves the right to determine performance measure groups which shall be subject to the sanction provisions for the Specialty Plan performance measures. D. Other Sanctions There are no additional provisions unique to the Specialty Plan. E. Notice of Sanctions There are no additional notice provisions unique to the Specialty Plan. F. Dispute of Sanctions There are no additional dispute provisions unique to the Specialty Plan. Section XII. Special Terms and Conditions The Special Terms and Conditions in Section XII, Special Terms and Conditions apply to the Specialty Plan unless specifically noted otherwise in this Exhibit. Section XIII. Liquidated Damages A. Damages Additional damages issues and amounts unique to this Specialty Plan are specified below. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 12 of 13

13 B. Issues and Amounts 1. Specialty Plan-Specific Liquidated Damages a. In addition to the provisions set forth in Attachment II and its Exhibits, if the Specialty Plan fails to perform any of the services set forth in the Contract, the Agency may assess liquidated damages for each occurrence listed in the Issues and Amounts Table below. Liquidated Damages Issues and Amounts # MMA PROGRAM ISSUES DAMAGES 1. Failure to verify specialty population eligibility criteria of an enrolled recipient within the timeframes in the Specialty Plan s policies and procedures. 2. Failure to comply with required Specialty Plan policies and procedures subject to Agency approval pursuant to the Contract. $150 per day for every day beyond the enrollment date. $1,000 per occurrence. b. In addition to the provisions set forth in Attachment II and its Exhibits, the Agency will review the Specialty Plan s performance related to the performance measures specified heretofore to determine acceptable performance levels and may set liquidated damages for these measures based on those levels after the first year the Contract. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. FP###, Attachment II, Exhibit II-C, Effective 02/01/18, Page 13 of 13